signal intensity in the parieto-occipital region (arrowheads ) and a more recent clot as deoxyhemoglobin in the frontal region (arrows ) B2: Axial T2WI shows the frontal parasagittal hemorrhagic areas of injury (arrows ) B3: Axial T2WI shows the posterior, parieto-occipital older areas of injury as areas of bleeding with blood fluid levels (arrowheads ) B4: Coronal T2WI through the frontal region shows bilateral parasagittal hemorrhagic changes (arrows ) B5: Coronal T2WI at the site of fracture (arrow ) shows overlying scalp swelling and bleeding C: Five-month-old male infant examined by CT and MRI on the day of admission Parts C1 and C2, axial CTs without contrast; parts C3 to C6, MRI images C1: Axial CT, brain windows, shows hemorrhage within the soft tissues of the scalp; underlying hypodensity and hyperdensity within the brain in the right parietal region consistent with contusional change C2: Axial bone window at the same level as C1 shows a fracture of the right parietal bone (arrow ) and an additional area of fracture posteriorly at the lambdoid suture (arrowhead ) C3: Coronal T2WI demonstrates separation of the bone at the site of fracture (arrow ) and underlying brain swelling involving the cortex, consistent with contusion (arrowheads ) Abnormality is present at the site of the fracture in the extracalvarial soft tissues, consistent with hemorrhage and/or herniation of brain tissue through the fracture C4: Axial two-dimensional FLASH susceptibility gradient echo scan demonstrates extensive intraparenchymal and soft-tissue scalp areas of signal loss consistent with bleeding C5: Axial diffusion imaging through the site of contusion shows restricted motion of water consistent with cytotoxic edema (arrowheads ) C6: Axial apparent diffusion coefficient (ADC) map at the site of the restricted motion of water shows hypointensity consistent with cytotoxic edema D: Four-month-old male infant examined by CT on the day of presentation (noncontrast study) D1: Axial image shows bilateral hypodense fluid collection surrounding the frontal lobes The temporo-occipital gray–white matter shows loss of definition bilaterally (arrows ) consistent with injury D2: Axial CT at a higher level in the brain shows the same findings as in A D3: Still higher axial CT shows extensive subdural hemorrhage on the left side covering the frontal lobe (arrows ) and extending into the midline along the falx cerebri E: Four-month-old male infant (same as D) examined on the day of presentation E1: Axial T2WI shows bilateral subdural fluid collection surrounding the frontal lobes There is abnormal subtle increased T2 signal intensity in the cortex both anteriorly and posteriorly within the brain (arrows ) There is sparing of the Rolandic region E2: Axial T2WI at a lower level shows the same findings E3: Axial T2WI gradient echo susceptibility scan shows extensive area of hemorrhage in the subdural space overlying the left parietal region (arrow ) E4: Axial diffusion weighted image shows bilateral temporo-occipital areas of restricted diffusion consistent with cytotoxic edema (arrows ) Note anteriorly in the region of the gyrus rectus that there is also bilateral cytotoxic edema (arrowheads ) E5: Axial ADC map at a higher level in the brain shows the hypointense signal in the bilateral parasagittal watershed region frontally, consistent with cytotoxic edema, as well as posteriorly in the bilateral parietal region E6: Coronal diffusion weighted image shows bilateral parasagittal posterior frontal areas of cytotoxic edema and bilateral temporal watershed areas (arrows ) E7: Coronal ADC map of these injuries shows hypointense signal at the site of cytotoxic edema (All images courtesy of Robert A Zimmerman, MD.) Suggested Readings and Key References General Physical Abuse/Assault American College of Radiology ACR-SPR practice parameter for skeletal surveys in children “Diagnostic Radiology” Radiography practice parameters and technical standards Revised 2016 Available at https://www.acr.org/-/media/ACR/Files/Practice-Parameters/SkeletalSurvey.pdf Accessed July 22, 2019 Berger RP, Lindberg DM Early recognition of physical abuse: bridging the gap between knowledge and practice J Pediatr 2019;204:16–24 Christian CW, Committee On Child Abuse and Neglect, American Academy of Pediatrics The evaluation of suspected child physical abuse Pediatrics 2015;135(5):e1337–e1354 Duffy SO, Squires J, Fromkin JB, et al Use of skeletal surveys to evaluate for physical abuse: analysis of 703 consecutive skeletal surveys Pediatrics 2011;127(1):e47–e52 Flaherty EG, Thompson R, Litrownik AJ, et al Effect of early childhood adversity on child health Arch Pediatr Adolesc Med 2006;160(12):1232–1238 Pierce MC If you build it, will they come? Getting medical professionals to use the bridge of evidence for improved recognition of physical child abuse J Pediatr 2019;204:13–15 Section on Radiology, American Academy of Pediatrics Diagnostic imaging of child abuse Pediatrics 2009;123(5):1430–1435 Sheets LK, Leach ME, Koszewski IJ, et al Sentinel injuries in infants evaluated for child physical abuse Pediatrics 2013;131(4):701–707 U.S Department of health & human services, administration for children and families, administration on children, youth and families, children’s bureau (2019) Child maltreatment 2017 Available at https://www.acf.hhs.gov/cb/research-data-technology/statistics-research/childmaltreatment Accessed July 22, 2019 Abusive Cutaneous Injuries Anderst JD, Carpenter SL, Abshire TC Evaluation for bleeding disorders in suspected child abuse Pediatrics 2013;131(4):e1314–e1322 Feldman KW The bruised premobile infant: should you evaluate further? Pediatr Emerg Care 2009;25(1):37–39 Kemp AM, Maguire SA, Nuttall D, et al Bruising in children who are assessed for suspected physical abuse Arch Dis Child 2014;99(2):108–113 Kemp AM, Maguire SA, Lumb RC, et al Contact, cigarette and flame burns in physical abuse: a systematic review Child Abuse Review 2014;23(1):35–47 Maguire S, Mann M Systematic reviews of bruising in relation to child abuse— what have we learnt: an overview of review updates Evid Based Child Health 2013;8(2):255–263 Pawlik MC, Kemp A, Maguire S, et al; ExSTRA investigators Children with burns referred for child abuse evaluation: burn characteristics and co-existent injuries Child Abuse Negl 2016;55:52–61 Pierce MC, Kaczor K, Aldridge S, et al Bruising characteristics discriminating physical child abuse from accidental trauma Pediatrics 2010;125(1):67–74 Sugar NF, Taylor JA, Feldman KW Bruises in infants and toddlers: those who don’t cruise rarely bruise Puget sound pediatric research network Arch Pediatr Adolesc Med 1999;153(4):399–403 Wood JN, Fakeye O, Mondestin V, et al Development of hospital-based guidelines for skeletal survey in young children with bruises Pediatrics 2014;135(2):e312–320 Abusive Oropharyngeal Injuries Fisher-Owens SA, Lukefahr JL, Tate AR Oral and dental aspects of child abuse and neglect Pediatrics 2017;140(2):e20171487 Rees P, Al-Hussaini A, Maguire S Child abuse and fabricated or induced illness in the ENT setting: a systematic review Clin Otolaryngol 2017;42(4):783–804 Abusive Fractures Flaherty EG, Perez-Rossello JM, Levine MA, et al Evaluating children with fractures for child physical abuse Pediatrics 2014;133(2):e477–e489 Leventhal JM, Martin KD, Asnes AG Incidence of fractures attributable to abuse in young hospitalized children: results from analysis of a United States database Pediatrics 2008;122(3):599–604 Maguire S, Cowley L, Mann M, et al What does the recent literature add to the identification and investigation of fractures in child abuse: an overview of review updates 2005–2013 Evid Based Child Health 2013;8(5):2044–2057 Ravichandiran N, Schuh S, Bejuk M, et al Delayed identification of pediatric abuse-related fractures Pediatrics 2010;125(1):60–66 Taitz J, Moran K, O’Meara M Long bone fractures in children under years of age: is abuse being missed in emergency department presentations? J Paediatr Child Health 2004;40(4):170–174 Wood JN, Fakeye O, Mondestin V, et al Prevalence of abuse among young children with femur fractures: a systematic review BMC Pediatr 2014;14:169 Abusive Head Trauma Boehnke M, Mirsky D, Stence N, et al Occult head injury is common in children with concern for physical abuse Pediatr Radiol 2018;48(8):1123–1129 Choudhary AK, Servaes S, Slovis TL, et al Consensus statement on abusive head trauma in infants and young children Pediatr Radiol 2018;48:1048–1065 Flom L, Fromkin J, Panigrahy A, et al Development of a screening MRI for infants at risk for abusive head trauma Pediatr Radiol 2016;46(4):519–526 Jenny C, Hymel KP, Ritzen A, et al Analysis of missed cases of abusive head trauma JAMA 1999;281(7):621–626 Maguire SA, Kemp AM, Lumb RC, et al Estimating the probability of abusive head trauma: a pooled analysis Pediatrics 2011;128(3):e550–e564 Maguire SA, Watts PO, Shaw AD, et al Retinal hemorrhages and related findings in abusive and non-abusive head trauma: a systematic review Eye (Lond) 2013;27(1):28–36 Rubin DM, Christian CW, Bilaniuk LT, et al Occult head injury in high-risk abused children Pediatrics 2003;111(6):1382–1386 Abusive Abdominal Trauma Lindberg D, Makoroff K, Harper N, et al Utility of hepatic transaminases to recognize abuse in children Pediatrics 2009;124(2):509–516 Maguire SA, Upadhyaya M, Evans A, et al A systematic review of abusive visceral injuries in childhood—their range and recognition Child Abuse Negl 2013;37(7):430–435 Trokel M, DiScala C, Terrin NC, et al Blunt abdominal injury in the young pediatric patient: child abuse and patient outcomes Child Maltreat 2004;9(1):111–117 Wood J, Rubin DM, Nance ML, et al Distinguishing inflicted versus accidental abdominal injuries in young children J Trauma 2005;59(5):1203–1208 Abusive Dental Trauma Vadiakas G, Roberts MW, Dilley DC Child abuse and neglect: ethical issues for dentistry J Mass Dent Soc 1991;40:13–15 ... Academy of Pediatrics Diagnostic imaging of child abuse Pediatrics 2009;123(5):1430–1435 Sheets LK, Leach ME, Koszewski IJ, et al Sentinel injuries in infants evaluated for child physical abuse Pediatrics... identification of pediatric abuse-related fractures Pediatrics 2010;125(1):60–66 Taitz J, Moran K, O’Meara M Long bone fractures in children under years of age: is abuse being missed in emergency department... abuse from accidental trauma Pediatrics 2010;125(1):67–74 Sugar NF, Taylor JA, Feldman KW Bruises in infants and toddlers: those who don’t cruise rarely bruise Puget sound pediatric research network